medical error

WHO report

the World Health Organisation (WHO) published a report on patient safety in December 2001 quoting several national surveys, which indicate that ‘adverse events’ (unanticipated problems which cause harm) occur in around 10% of all health care interventions in the US, Australia, UK, and Denmark. clearly the problem is grievous and costly, yet it attracts little media attention, few prosecutions, and little inclination for systemic change to tackle it. the WHO subsequently published a resolution urging member states to improve monitoring procedures and foster better practices.

learning from mistakes

there need to be national bodies (‘patient safety observers’) set up to:

• monitor, investigate and document medical errors and ‘near misses’
• identify patterns leading to error
• instigate research into improvements to existing medical procedures or alternatives
• compile a freely-accessible knowledgebase of best practice

to avoid conflicts of interest, patient safety observers should:

• be directly funded by, and answerable to, government not hospitals
• not lead investigations into criminal negligence (though they should be required to co-operate with such investigations)
• have powers to subpoena medical staff, suppliers of drugs, and suppliers and maintainers of medical equipment
• preserve the anonymity of all parties to an investigation (except in cases of criminal negligence)

the WHO, or an international body under its aegis, should:

• co-ordinate the work of national bodies and disseminate the findings
• maintain a public international directory of health workers barred from practice, and of suppliers found guilty of negligent or unethical practices

negligence

there must not be an assumption that error implies negligence: the full co-operation of doctors, nurses, patients and others is necessary if facts are to be established with minimal disruption and distress. changes to procedure and/or retraining should follow as soon as possible. where negligence or incompetence is uncovered, then disciplinary or criminal procedures should take their course.

reparation

whether or not someone can be blamed should not determine the extent and terms of reparation available to a victim of a medical error, and/or their family. though this is a debatable issue of justice, a ‘no blame’ policy of reparation (medical, psychological, practical or financial) for all ‘adverse events’ would be advantageous to both victims and health professionals.

further reading

• WHO : Quality of care: patient safety – resolution
• National Patient Safety Agency (UK)
• National Institute for Clinical Excellence (UK)
• Cure Research : Medical Mistakes
• Harvard Medical International : Tackling Medical Error

news articles

• One in three medical errors ‘procedural’ (BBC)
• NHS Watchdog to Monitor Operations (BBC)
• Surgeon Hid Ban to Get Work (BBC)
• Firm Silent As Patients Died (Washington Post)
• Human Error Causes of Medication Errors Discovered (Doctor’s Guide)

contributors

Edward Leigh, Len Caune